Acne Vulgaris is one of the most common skin disorders which dermatologists have to treat. It mainly affect adolescent, though may present at any age. In recent years, due to better understanding of the pathogenesis of acne, new therapeutic modalities and various permutation and combinations have been designed. In topical agents; benzoyl peroxide, antibiotics, retinoids, etc are the mainstay of treatment; can be given in combinations. While systemic therapy includes oral antibiotics, hormonal therapy, and isotretinoin, depending upon the need of patients it has to be selected. Physical treatment in the form of lesion removal, photo-therapy is also helpful in few of them. Since various old and new topical and systemic agents are available to treat acne, it sometime confuse treating dermatologist. To overcome this, panel of physicians and researchers worked together as a global alliance and task force to improve outcomes in acne treatment. They have tried to give consensus recommendation for the treatment of acne. Successful management of acne needs careful selection of anti-acne agents according to clinical presentation and individual patient needs.

Background: Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), are the acute emergencies in dermatology practice. Prompt diagnosis and management may reduce the morbidity and mortality in SJS/TEN patients. Early identification of the offending drug is necessary for early withdrawal and to prevent the recurrences of such a devastating illness. Aims : To study the demography, offending agents, clinical and laboratory features, treatment, complications, morbidity and mortality of SJS/TEN in our hospital. Materials and Methods: In this retrospective study, we reviewed the medical records of SJS, TEN, SJS/TEN overlap of inpatients over a period of 10 years Results: Maximum number of SJS/TEN cases were in the age group of 11-30 years. Males predominated in the SJS group with a ratio of 1.63:1, whereas females predominated the TEN group with a ratio of 1:2.57. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the commonest group of drugs among the SJS group in 5/21 patients (23.8%). Antimicrobials were the commonest group of drugs causing TEN in 11/25 patients (44%). Mucosal lesions preceded the onset of skin lesions in nearly 50%. Our study had one patient each of SJS/TEN due to amlodipine and Phyllanthus amarus, an Indian herb. The most common morbidity noted in our study was due to ocular sequelae and sepsis leading to acute renal failure respectively. Kaposi's varicelliform eruption was found in three of our patients. Conclusion: Antimicrobials and NSAIDS are the common offending agents of SJS/TEN in our study.

This is a case series of allopurinol-induced toxic epidermal necrolysis. Revisiting the indications of using allopurinol in asymptomatic hyperuricemia and a critical reappraisal of the safety profile of allopurinol is done in this article. The report is based on case presented at a tertiary hospital in Singapore. The aim of this study is to highlight the fatal consequences of the indiscriminate use of allopurinol. We report four cases of toxic epidermal necrolysis from allopurinol, three of which resulted in death. Our aim is to highlight that allopurinol in all these cases was not indicated and prescribed for asymptomatic hyperuricemia. The incidence and potentially severe and lethal consequences of allopurinol hypersensitivity syndrome and toxic epidermal necrolysis could be kept to a minimum by strictly adhering to the established indications of allopurinol treatment.

Background: Recently, we noted increasing number of cases of Kaposi's varicelliform eruption (KVE) among dermatology in-patients who were being treated for various dermatoses, some of which have not been reported earlier to be associated with KVE, and hence, this report. Aims: This study was designed to identify various dermatoses in which KVE occurred, to study the clinical features, course and response to specific antiviral treatment, to establish the risk factors, and course of the primary dermatoses during the episode of KVE. Materials and Methods: We analyzed our data of dermatology in-patients in a tertiary care centre in South India from April 2008 to November 2009 (20 months). The data were tabulated and analyzed. Results: Twenty cases (12 female and 8 male patients) of KVE were seen. The mean age of the patients was 46.4 years. There were seven cases of erythroderma, four of pemphigus vulgaris, three of toxic epidermal necrolysis, two of airborne contact dermatitis (ABCD), one each of lichenoid drug rash, and drug rash with eosinophilia and systemic symptoms (DRESS). Underlying dermatoses for erythroderma were: ABCD (3), psoriasis (3), and cutaneous T-cell lymphoma (1). Possible source of infection could be identified in five cases: exogenous sources in four cases and endogenous source in one case. The mean incubation period for cases with known source was 5 days (range, 2-9 days). Eighteen patients responded favorably to acyclovir. None of our patients had recurrent KVE during the study period. Conclusion: KVE may complicate any dermatosis where the integrity of the skin is compromised. Diagnosis and early treatment are important and possible in most cases if suspected.

Congenital cutaneous candidiasis (CCC) is an extremely rare disorder that presents within the first 6 days of life. The manifestations ranges from diffuse skin eruption without any systemic symptoms to respiratory distress, hepatosplenomegaly, sepsis, and death. We report a neonate who presented with generalized skin eruptions at birth, characterized by erythematous macules and papules. The eruption involved head, face, neck, trunk, and extremities. Candida albicans was demonstrated on direct KOH smear, skin biopsy. The disease implies a congenital intrauterine infection and is different from neonatal candidiasis, which manifests as thrush or diaper dermatitis. The infection is acquired from the maternal genital tract in an ascending fashion. Clinical features, direct smear examination of specimen, and appropriate cultures are useful in differentiating the lesions from other more common dermatoses of the neonatal period. Topical antifungal therapy is sufficient unless systemic candidiasis is present. Prognosis for congenital cutaneous candidiasis is good.

Vulvo-perineal Crohn's disease is a rare condition either when it is isolated or associated with digestive manifestations. In the former condition named metastatic Crohn's disease, it may constitute a diagnostic challenge and may be confused especially with other infectious or inflammatory disorders. We report a case of vulvo-perineal Crohn's disease in a 46-year-old woman. A 46-year-old woman was diagnosed with a vulvo-perineal Crohn's disease without digestive involvement. There was a chronic edema of the vulva with linear ulcerations on the inguino-crural regions and the buttocks fold, of 3 years. Treatment with metronidazole (1 g/day for 6 months) led to almost complete healing of the ulcerations with a sustained result. Physicians must be aware of the diverse manifestations and confusing presentations of vulvo-perineal Crohn's disease.

Background: Hair loss is seen as an irreversible process. Most research concentrates on how to elongate the anagen, reduce the negative factors of obstructing hair growth and improve the hair number and size. Aim: In our experiment, we tried to prove that the cow placenta extract can promote hair growth by elongating hair shaft and increasing hair follicle number. Materials and Methods: Cow placenta extract (CPE), water and minoxidil applied separately on the back of depilated B57CL/6 mice for the case, negative and positive control respectively. We checked the proliferation of cells which are resident in hair sheath, and the expression of a few growth factors which stimulate hair growth. Results: Result shows that placenta extract more efficiently accelerates cell division and growth factor expression, by raising the insulin-like growth factor (IGF-1) mRNA and protein level to increase HF size and hair length. Conclusions: The extract is not a purified product; so, it is less effective than minoxidil, which is approved by the US FDA for the treatment of male pattern baldness. If refinement is done, the placenta extract would be a good candidate medicine for hair loss.

Background: Topical corticosteroids were first introduced for use in 1951. Since then uncontrolled use (abuse) has caused many different reactions resembling rosacea - steroid dermatitis or iatrosacea. Multiple pathways including rebound vasodilatation and proinflammatory cytokine release have been proposed as the mechanism for such reactions. Aim: The aim was to study the adverse effects of topical steroid abuse and the response to various treatment modalities. Materials and Methods: Two hundred patients with a history of topical steroid use on face for more than 1 month were studied clinically and various treatments tried. Results: The duration of topical corticosteroid use varied from 1 month to 20 years with an average of 19.76 months. Majority of patients were using potent (class II) topical steroids for trivial facial dermatoses. The common adverse effects were erythema, telangiectasia, xerosis, hyperpigmentation, photosensitivity, and rebound phenomenon. No significant change in laboratory investigations was seen. Conclusion: A combination of oral antibiotics and topical tacrolimus is the treatment of choice for steroid-induced rosacea.

Cleansers and their role in various dermatological disordersPartha MukhopadhyayJanuary-February 2011, 56(1):2-6DOI:10.4103/0019-5154.77542 PMID:21572782

The art of cleansing has progressed immensely over several thousand years from simply scraping the skin to an exercise in relaxation and improvement in the skin's health and appearance in the present day. Soaps - the basic cleansing agent has also undergone a sea change in its evolution with many variants and newer constituents being incorporated into it. In dermatological disorders like acne, rosacea, atopic dermatitis, photoaging, 'sensitive skin', occupational dermatosis cleansers may have a beneficial role along with other therapeutic measures. With the advent of aesthetic dermatology, the act of cleansing and the use of various cleansing agents prior to aesthetic procedures has also assumed significance.

A 7-month old girl with GM1 gangliosidosis type 1 manifested with diffuse ecchymosis and Mongolian spots. The cutaneous lesions were present at birth before the appearance of the other features of the disease. We postulate that dermal pigmentation may be recognized as an early sign of GM1 gangliosidosis.

Porphyrias form a group of disorders caused due to defects in the haem synthetic pathway. Congenital erythropoietic porphyia (CEP) is the rarest of the bullous porphyrias (less than 200 cases have been reported till recent times) and a clinician may not see a case during his professional life. We present two cases of CEP. One child with CEP presented with typical infancy-onset blistering, photosensitivity, red urine, and erythrodontia, with hypertrichosis of the upper arms and back. The other child of CEP presented with childhood-onset blistering, mutilation, and hypertrichosis on the face.

Introduction: Appendageal skin tumors (ATs) are those neoplasms that differentiate toward/arise from pilosebaceous apparatus, apocrine, or eccrine sweat glands. Pilosebaceous apparatus are concentrated in head−neck area; thus it is expected that ATs would account for a major fraction of skin tumors over this site. Aims: This study aims at finding the clinico-histopathological correlation in cases ATs in head−neck region among attendees of dermatology OPD. Materials and Methods: Cross-sectional descriptive study, conducted over 1-year period. All clinically suspected cases of ATs were evaluated and subjected to histopathological examination. Confirmed cases of ATs were finally analyzed. Results : Among twenty eight thousand four hundred sixty six new patients attending OPD, 30 suspected cases of ATs underwent histopathological examination. Histopathology was confirmatory in only 23 (76.67%) cases. Out of 23, syringoma were found in 9 (39.13%), trichoepithelioma in 6 (26.08%), syringocystadenoma papilliferum in 4 (17.39%), sebaceous gland hyperplasia in 3 (13.04%), and vellous hair cyst in 1 (4.34 %). Females (65.21%) outnumbered males (34.78%) in our study population. Conclusions: ATs of head−neck region constitute a meager population (0.08%) attending dermatology OPD, and were more common among young population. Often it is over-diagnosed clinically thus necessitating histological confirmation. Young females being cosmetically more conscious are more eager to seek advice for this condition.

Background : Palmoplantar psoriasis is a frequently encountered variant of psoriasis. It is difficult to treat and even more difficult to maintain remission as it is exacerbated by friction and trauma of the patient's daily activities. Existing topical modalities of treatment are often inadequate and show unpredictable response. Aim : To study the efficacy and safety of a newer retinoid, tazarotene, as 0.1% cream in the treatment of palmoplantar psoriasis. Materials and Methods : Thirty adult patients with palmo-plantar psoriasis were randomized to therapy with once daily application of topical tazarotene cream (0.1%) or once daily application of clobetasol propionate cream (0.05%) for 12 weeks. The patients were assessed every 2 weeks for improvement in Erythema, Scaling, Fissures and Induration (ESFI) score and Physicians Global Assessment Scale. Results : At 12 weeks, the tazarotene group showed mean ESFI reduction to 1.12 (83.2%) from 6.65 at baseline. Complete clearance was noted in 52.9% of the patients. Clobetasol propionate group showed mean ESFI reduction to 0.62 (89.1%) from 5.69 at baseline, with complete clearance in 61.5% of the patients. Differences between the two groups were statistically insignificant. Side effects observed were initial irritation (41%) in the tazarotene group and hypopigmentation (53.8%) in the steroid-treated patients. Conclusion : Tazarotene is as effective as clobetasol propionate and provides a good alternative for the treatment of palmo-plantar psoriasis where hypopigmentation limits the use of clobetasol propionate cream.

Nephrogenic systemic fibrosis (NSF) was first described in 2000 as a scleromyxedema-like illness in patients on chronic hemodialysis. The relationship between NSF and gadolinium contrast during magnetic resonance imaging was postulated in 2006, and subsequently, virtually all published cases of NSF have had documented prior exposure to gadolinium-containing contrast agents. NSF has been reported in patients from a variety of ethnic backgrounds from America, Europe, Asia and Australia. Skin lesions may evolve into poorly demarcated thickened plaques that range from erythematous to hyperpigmented. With time, the skin becomes markedly indurated and tethered to the underlying fascia. Extracutaneous manifestations also occur. The diagnosis of NSF is based on the presence of characteristic clinical features in the setting of chronic kidney disease, and substantiated by skin histology. Differential diagnosis is with scleroderma, scleredema, scleromyxedema, graft-versus-host disease, etc. NSF has a relentlessly progressive course. While there is no consistently successful treatment for NSF, improving renal function seems to slow or arrest the progression of this condition. Because essentially all cases of NSF have developed following exposure to a gadolinium-containing contrast agent, prevention of this devastating condition involves the careful avoidance of administering these agents to individuals at risk.

Background: Although cryotherapy is still the first-line therapy for solar lentigines, because of the side effects such as post-inflammatory hyperpigmentation (PIH), especially in patients with darker skin types, pigment-specific lasers should be considered as a therapy for initial treatment. Aim: The aim of this study is to evaluate the efficacy and safety of cryotherapy compared with 595-nm pulsed dye laser (PDL) with cutaneous compression in the treatment of solar lentigines. Materials and Methods: Twenty-two patients (skin type II−IV) with facial or hand lentigines participated in this study. Lesions of one side of the face or each hand were randomly assigned and treated with either cryotherapy or PDL. Treatments were performed with radiant exposures of 10 J/cm 2 , 7-mm spot size and 1.5 ms pulse duration with no epidermal cooling. Photographs were taken before treatment and 1-month later. The response rate and side effects were compared. Results: PDL was more likely to produce substantial lightening of the solar lentigines than cryotherapy, especially in skin type III and IV (n = 8, n = 9; P < 0.05), but might be no difference in type II (n = 5; P > 0.05). PIH was seen only in cryotherapy group. PDL group had only minimal erythema. No purpura was observed. Conclusion: PDL with compression is superior to cryotherapy in the treatment of solar lentigines in darker skin types.

The primary cutaneous T-cell lymphomas (CTCL) represent a clonal T-lymphocyte proliferation infiltrating the skin. CD30+ T-cell lymphomas present clinically as nodules with a diameter between 1 and 15 cm, mostly in elderly patients. The role of the CD30 molecule in patients suffering from T-cell lymphomas is not completely clear yet. The signal transduction pathway which includes CD30 seems to play a key role in tumor progression. In certain forms of T-cellular lymphomas, the interaction between CD30/CD30-ligand is able to provoke apoptosis of the "tumor lymphocytes". The modern conceptions of the pathogenesis of T-cell lymphomas include disorders in the pathways involved in programmed cellular death and disregulation in the expression of certain of its regulatory molecules. We are presenting an unusual case of a female patient with a primary cutaneous form of CD30 + /ALK− anaplastic large T-cell lymphoma. Upon the introduction of systemic PUVA, (psoralen plus ultraviolet light radiation) combined with beam therapy, a complete remission could be noticed. Eight months later, we observed a local recurrence, which was overcome by CHOP chemotherapy (Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Vincristin (Oncovin®), Predniso(lo)n). Six months later, new cutaneous lesions had been noticed again. A new therapeutic hope for the patients with anaplastic large CTCL is actually based on the influence of the activity of the different apoptotic pathways. Death ligands, including tumor necrosis factor (TNF)-α, CD95L/FasL, and TRAIL, mediate also some important safeguard mechanisms against tumor growth in patients with CD30 + cutaneous anaplastic large T-cell lymphomas and critically contribute to lymphocyte homeostasis.

Lymphangioma circumscriptum (LC), a hamartomatous lymphatic malformation, is a therapeutic challenge for the dermatologist. Various modalities like surgical excision, lasers, and sclerotherapy have been used in the past to treat this notorious skin condition. We report the efficacy of a radiofrequency ablation in a patient with LC. The treatment efficacy of radiofrequency was satisfactory in our patient with no recurrence during 1 year follow-up period. The radiofrequency technique is a safe and economic treatment for management of LC.

Churg-Strauss Syndrome (CSS) is rare in children. It consists of a small- and medium-sized vessel vasculitis, with skin and peripheral nerve involvement. It is characterized by eosinophilia, extravascular necrotizing granuloma, and eosinophilic infiltration of multiple organs particularly the lungs, but may also involve the gastrointestinal tract, the heart, and the kidneys. The condition is usually associated with a preceding history of asthma or allergic sinusitis. It has rarely been reported in children, where most of the cases had pre-existing asthma, allergic rhinitis, or atopic disease. We report a 10-year-old Arab girl proven to have CSS, with no history of asthma or allergic rhinitis, who presented with tender cutaneous nodules of lower extremities, foot drop, and peripheral eosinophilia, without any clinical respiratory symptoms or signs.

Nephrogenic systemic fibrosis (NSF) has now been virtually eliminated by the discovery of its association with gadolinium-based contrast agents (GBCAs) and the consequent reduced use of GBCA-enhanced magnetic resonance imaging (MRI) in severe renal failure patients. This review of 408 biopsy-confirmed cases shows how to minimize NSF risk when performing GBCA-enhanced MRI or magnetic resonance angiography. The absence of any NSF cases in patients less than 8 years old or greater than 87 years old suggests that infants and elderly patients are already protected. Limiting GBCA dose to a maximum of 0.1 mMol/kg, dialyzing dialysis patients quickly following GBCA administration, delaying administration of GBCA in acute renal failure until after renal function returns or dialysis is initiated, and avoiding nonionic linear GBCA in renal failure patients, especially when there are pro-inflammatory conditions, appear to have reduced NSF risk to the point where safe GBCA-enhanced MRI is possible in most patients.

Background: Glucantime is regarded as the first-line treatment of cutaneous leishmaniasis (CL); however, failure to treatment is a problem in many cases. Aim: The aim was to evaluate the therapeutic effect of glucantime in CL complicated with secondary bacterial infection compared to uncomplicated lesions. Methods: This experimental study was performed in Skin Diseases and Leishmaniasis Research Center, Isfahan, Iran. A total of 161 patients enrolled in the study had CL confirmed by positive smear of lesions. All the patients were treated with systemic glucantime for 3 weeks and followed for 2 months. Response to treatment was defined as loss of infiltration, reepithelization, and negative smear. Depending on the results of bacterial cultures, the lesions were divided into two groups and the efficacy of glucantime was compared. Results: A total of 123 patients (76.4%) were negative, and 38 patients (23.6%) were positive for secondary bacterial infection. In groups with negative bacterial culture response to treatment was 65% (80 patients) and in the other positive group, it was 31.6% (12 patients), with a difference (χ2 = 13.77, P < 0.01). Conclusion: Therapeutic effect of glucantime showed a decrease in CL lesions with secondary bacterial infection. Therefore, in the cases of unresponsiveness to treatment, the lesions should be evaluated for bacterial infection, before repeating the treatment.

The use of narrow band ultraviolet light B in the prevention and treatment of postherpetic neuralgia (A pilot study)Eman El-NabarawyJanuary-February 2011, 56(1):44-47DOI:10.4103/0019-5154.77551 PMID:21572791

Background: Postherpetic neuralgia (PHN) is a common complication of herpes zoster that is frequently unresponsive to most of the available treatment modalities. Broad band ultraviolet B radiation (UVB) has a well-known anti-inflammatory effect. Moreover, it decreases neural damage and cutaneous nerve density. It was found that broad band UVB might have a role in the prevention and treatment of PHN. Aim: This study was carried out to evaluate the effect of narrow band UVB (nbUVB) in the treatment PHN. Patients and Methods: The study included 17 patients with distressing post herpetic neuralgia. Patients were evaluated using the Verbal Rating Scale (VRS). The patients received nbUVB sessions, three times a week, for a total of 15 sessions or until the pain disappeared. Patients were followed up for a period of 3 months after the end of therapy. Results: Using intention to treat analysis, more than 50% improvement was achieved in 6 (35.29%) and 8 (47.06%) patients, at the end of therapy and after 3 months follow up, respectively. An improvement less that 50% was achieved in 11 (64.71%) and 9 (52.94%) patients, at the end of therapy and after 3 months follow up, respectively. The pain severity assessed by the VRS significantly improved both at the end of sessions (P = 0.005) and after 3 months follow up (P = 0.005). Conclusion: nbUVB may be of beneficial use in the treatment of PHN. Limitation: Small number of patients and limited follow-up period.

Melanoacanthoma denotes a rare variant of pigmented seborrheic keratosis. A 65-year-old male farmer had pigmented, verrucous, itchy, highly painful, progressively growing irregularly oval plaque on left side of lower back for the past five years. The indurated lesion, measuring maximum diameter 10 cm Χ 5 cm, had no discharge, bleeding, ulceration, or associated lymphadenopathy. Dermoscopy showed regular pigmentary network and cribiform pattern of ridges without any feature of malignant melanoma. Histopathology showed well-defined islands of basaloid cells interspersed with large and richly dendritic melanocytes. The lesion was totally excised followed by skin grafting. Our patient was unique in its massive size and clinical resemblance with malignant melanoma. The diagnosis was confirmed by dermoscopy and skin biopsy.

Nephrogenic systemic fibrosis is a fibrosing disorder of the skin that develops in patients with advanced renal failure. It mostly presents with progressive hardening or induration of the skin of the extremities. Systemic involvement is also known to occur in this entity. Exposure to gadolinium contrast for radiological evaluation has been identified as the offending agent. The condition is progressive and can be seriously disabling. Therapeutic options are limited and not rewarding in majority of the cases. Awareness of this entity is important so that proper precautionary measures can be taken at the earliest to ameliorate the condition.

Hypereosinophilic syndrome (HES) encompasses a group of leukoproliferative disorders with variable involvement of the internal organs. More than half of all patients have cutaneous involvement. In a minority of the reported cases, skin involvement has been the only manifestation of HES . We report one such rare case of HES, with cutaneous involvement as the sole manifestation.

Cutaneous pseudolymphomas are a group of benign reactive T or B cell lymphoproliferative processes of diverse etiology that simulate cutaneous lymphomas clinically and histologically. We report one such case of pseudolymphoma occurring in the groin of an elderly lady with a history of excision arthroplasty and cementing done at the same site decades ago.

Effect of age on the biomechanical and microcirculatory properties of the skin in healthy individuals and during venous ulcerationEssam H MattarJanuary-February 2011, 56(1):19-24DOI:10.4103/0019-5154.77545 PMID:21572785

Background: With aging there is alteration of elastic properties of the skin and skin-blood flow. Aim: The purpose of this study was to compare age-related changes in selected biomechanical parameters of the skin (skin hardness, skin extensibility, relaxation time constant, τ) and subcutaneous microcirculatory quality (SMQ) in individuals with and without venous diseases. Materials and Methods: Two groups were studied: the first group was of asymptomatic healthy individuals and the second group included patients with chronic venous insufficiency (CVI) and venous ulceration, without edema. Both groups were subdivided to three age categories (21-40, 41-60 and 61-90 years old). Skin hardness was measured by durometer, extensibility and τ were measured using extensometer and SQM was assessed via postural vasoconstrictive response (LDF). Results: Results showed that skin hardness, extensibility, and τ-values were increased, whereas LDF was decreased in the older groups as compared with younger groups. These changes are attributed to alterations in the skin structure and reduced capillaries density networks. Similar behavior was found in the biomechanical and microcirculatory changes in patients with venous ulceration and CVI, but these changes were more increased further in older patients with venous ulceration as compared with older patients with CVI and that can be attribute to more intense response against tissue injury. Conclusions: Since aging elevated skin hardness and extensibility, but lowered vasoconstrictive response in individuals, with and without, venous diseases, we conclude that aging process is likely to cause an accumulation of damaged skin tissues and that could induce an apparent antigen-driven response that altered skin structure and the subsequent biomechanical properties obtained in this study.

Patients on anti-TNFα therapy are at increased risk for rare opportunistic infections. Here we are reporting a case of Scedosporium apiospermum infection in a patient treated with anti-TNF for 5 years. Patients on anti-TNFα need close follow-up and clinicians should be suspicious for atypical infections in these immunocompromised hosts.